Download Prophylactic Pre-Operative Coronary Revascularization

Journal of the American College of Cardiology
© 2009 by the American College of Cardiology Foundation
Published by Elsevier Inc.
EDITORIAL COMMENT
Prophylactic Pre-Operative
Coronary Revascularization
Is the Phoenix Awakening?*
Giora Landesberg, MD, DSC,†
Morris Mosseri, MD‡
Jerusalem and Kfar-Saba, Israel
Exactly 30 years ago, Hertzer et al. (1) published the first in a
series of reports on thousands of patients who underwent
routine coronary angiography before major vascular surgery.
Their landmark studies were the basis for our current recognition that vascular surgery patients have a high prevalence of
significant coronary artery disease (CAD): 60% have 1 or more
coronary arteries with ⬎70% stenosis, 18% have severe triplevessel disease, and 4% have left main disease (2). Subsequently,
Hertzer et al. (1) showed that selective pre-operative coronary
artery bypass graft surgery (CABG) in patients with severe
CAD lowered the perioperative and long-term mortality relative to patients with similar degrees of CAD not treated with
CABG. Numerous subsequent studies confirmed that major
vascular surgery is associated with a high risk for both perioperative and long-term cardiac morbidity and mortality. Many
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other studies demonstrated that this risk is predicted by
ischemia on pre-operative noninvasive cardiac testing (radionuclide imaging or dobutamine stress echocardiography).
However, the data that pre-operative coronary revascularization (PCR), mainly by CABG, improves perioperative or
long-term outcome after major vascular surgery came from
retrospective observational studies only (3). Moreover, since
PCR is not free of complications, serious questions were raised
as to the overall risk-benefit ratio of PCR before major vascular
surgery, questions that could only be answered by large-scale
randomized controlled trials (RCTs).
Lately, 2 RCTs—the CARP (Coronary Artery Revascularization Prophylaxis) trial (4) and the DECREASE (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echo
Study Group)-V (5) study—examined the role of PCR before
*Editorials published in the Journal of the American College of Cardiology reflect the
views of the author and do not necessarily represent the view of JACC or the American
College of Cardiology.
From the †Cardiothoracic and Vascular Anesthesia Division, Hebrew University,
Hadassah Medical Center, Jerusalem, Israel; and the ‡Cardiology Division, Meir
Medical Center, Kfar-Saba, Israel.
Vol. 54, No. 11, 2009
ISSN 0735-1097/09/$36.00
doi:10.1016/j.jacc.2009.05.045
major vascular surgery. Both trials found absolutely no perioperative or long-term benefit to PCR over medical therapy before
vascular surgery. Unfortunately however, even these RCTs were
not free of serious limitations. The CARP trial screened 5,859
vascular surgery patients from 18 Veterans Administration hospitals in the U.S., yet without a unified method of screening in all
institutions. Subsequently, only a small proportion (8.9%) of
screened patients was randomized. Only 44% of randomized
patients had moderate-large ischemia on pre-operative nuclear
imaging, and only 32% had triple-vessel disease (2.9% of all
screened patients), indicating a potential selection bias with the
possibility that mainly patients less likely to benefit from PCR
were included in the trial. Patients with left-main CAD were
excluded by design from randomization. Moreover, on reanalysis
of the CARP study data, patients who had complete coronary
revascularization with CABG had fewer post-operative cardiac
complications (6), and among patients who were not included in
the randomization, those with left main disease had better survival
if treated with PCR (7). In contrast, the DECREASE-V trial
aimed to randomize patients with the most severe CAD. However, this relatively small trial (n ⫽ 101) eventually randomized
patients who were too ill for PCR and surgery. In the revascularization arm, 100% had history of myocardial infarction, 51% had
ongoing angina, 47% had congestive heart failure, 37% had
diabetes mellitus, 41% had a history of cerebrovascular accident,
and 18% had renal failure, in addition to extensive ischemia on
noninvasive pre-operative testing. Moreover, apparently all 49
patients randomly assigned to the revascularization arm were
compelled to undergo PCR, although most studies show that up
to one-third of vascular surgery patients with severe ischemia on
noninvasive testing cannot undergo coronary revascularization
because of unsuitable coronary anatomy, poor runoff, multiple
small-vessel disease, or chronic total obstructions not amenable to
percutaneous coronary intervention, or because they are too sick
for CABG. Subsequently, the DECREASE-V trial patients
suffered exceptionally high perioperative (11% to 22%) and 1-year
mortality regardless of PCR. The authors of this editorial have
previously shown that major vascular surgery patients with numerous risk factors have a poor post-operative prognosis irrespective of
PCR (8). Therefore, major vascular surgery patients deserve
careful pre-operative clinical assessment and judgment as to who
may or may not benefit from coronary intervention and strict,
blinded randomization can do harm to such patients.
Despite the above limitations, the impact of the CARP and
DECEASE-V trials on clinical practice and published guidelines
worldwide was enormous. Coronary revascularization is subsequently rarely recommended before major vascular surgery, and
even the demand for noninvasive pre-operative cardiac testing in
major vascular patients has decreased substantially. It is against this
background that the study by Monaco et al. (9) in this issue of the
Journal has surprisingly emerged.
Monaco et al. (9) elegantly showed in a RCT that a strategy
of routine pre-operative coronary angiography and subsequent
selective PCR provides better long-term survival and eventfree survival for patients undergoing abdominal aortic surgery,
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Landesberg and Mosseri
Pre-Operative Coronary Revascularization
compared with a strategy of selective coronary angiography and
PCR, performed only after pre-operative noninvasive testing
showing significant ischemia. There was also a tendency to
improved perioperative outcome (although not statistically
significant). Included in the randomization were all patients
with ⱖ2 RCRI criteria. Patients in the routine angiography
arm underwent more PCRs (58.1% vs. 40.1%; p ⫽ 0.01).
Interestingly, the beneficial effect of PCR in the routine
angiography arm was on top of strong beta-blockade with the
nonselective beta-blocker carvedilol, titrated to quite high
doses to reach the effect of resting pre-operative heart rate of
ⱕ60 beats/min. There are 2 main findings in this trial: 1) PCR
improves outcome for this subset of medium-high risk vascular
surgery patients; and 2) routine pre-operative coronary angiography provides better screening of vascular surgery patients
than does noninvasive testing.
How can we reconcile the sharp conflict between the
positive results of the trial by Monaco et al. (9) and the negative
results of the previous 2 RCTs? First, unlike the previous
RCTs, this trial included only patients undergoing abdominal aortic surgery and not lower extremity bypass operations. The latter are less stressful operations, associated with
lower perioperative morbidity and mortality. Clearly, the
DECREASE-V patients were much sicker, with more cardiac
and noncardiac comorbidities than the patients in the present
study with poorer prognosis regardless of any pre-operative
treatment. Conversely, the patients in the present trial had
more extensive CAD, including left main disease and a higher
prevalence of triple-vessel disease than the CARP trial patients. Importantly, patients in the systematic pre-operative
coronary angiography group underwent more PCRs with
off-pump CABG than PCI compared with the control group
(47.5% vs. 28.6%, respectively, with a tendency for statistical
significance: p ⫽ 0.08). It is possible, therefore, that more patients
with left main disease and triple-vessel disease underwent offpump CABG than PCI, and these results translated into a
significantly better long-term outcome in the systematic coronary
angiography group who underwent more CABG than PCI, in
corroboration with previous studies that found better outcome
with CABG than PCI in similar patients (6,10).
Will this new RCT lead to a change in practice back to
more pre-operative coronary revascularizations or to routine
coronary angiography as Hertzer advocated 30 years ago? Time
will tell. The study by Monaco et al. (9) suggests that routine
pre-operative coronary angiography is better than noninvasive
cardiac testing for detecting patients who may benefit from
successful PCR. This relatively small trial must be corroborated
by additional, preferably larger studies. The possibility of
screening patients by computed tomography or magnetic
resonance coronary angiography, rather than routine coronary
angiography, should also be explored. The current practice of
endovascular abdominal aneurysm repair, which is less stressful
and associated with fewer perioperative complications, diminishes, although does not eliminate, the need for open aortic
repairs, pre-operative cardiac evaluations, and eventual PCR.
JACC Vol. 54, No. 11, 2009
September 8, 2009:997–8
Nevertheless, it is safe to say, on the basis of currently
accumulated data, that vascular surgery patients, particularly
those with extensive and complex CAD and a high SYNTAX
(Synergy between PCI with TAXUS and Cardiac Surgery)
score (11), fare better in the long run with CABG than with
PCI (6,10). Moreover, the current guidelines demanding
prolonged dual-antiplatelet therapy, even after successful coronary stent implantation (at least 4 weeks for bare-metal stent
and up to 1 year after drug-eluting stent implantation), limit
the ability to use PCI as the method for coronary revascularization before major surgery. Above all, risk stratification of
patients who are candidates for vascular surgery is frequently
puzzling, and the treating physicians must rely on their best
medical judgment whether to pursue pre-operative noninvasive
or invasive testing as well as coronary revascularization procedures with these high-risk patients.
Reprint requests and correspondence: Dr. Giora Landesberg,
Hebrew University, Hadassah Medical Center, Department of
Anesthesiology and CCM, Kyriat-Hadassah, Ein Kerem, Jerusalem 91120, Israel. E-mail: [email protected].
REFERENCES
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Key Words: vascular surgery y risk stratification y coronary
angiography y peripheral vascular disease y revascularization.